|
PR TRIM NAIL(S)
|
Professional
|
$26.02
|
|
|
Service Code
|
CPT G0127
|
| Hospital Charge Code |
zG0127
|
| Min. Negotiated Rate |
$6.09 |
| Max. Negotiated Rate |
$19.52 |
| Rate for Payer: Aetna Medicare |
$7.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.88
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Coventry All Commercial |
$8.59
|
| Rate for Payer: Humana ChoiceCare |
$6.09
|
| Rate for Payer: Humana Medicare |
$7.16
|
| Rate for Payer: Lucent All Commercial |
$12.17
|
| Rate for Payer: PHCS All Commercial |
$19.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.16
|
| Rate for Payer: United Healthcare Commercial |
$10.00
|
| Rate for Payer: United Healthcare Medicare |
$7.16
|
|
|
PR TUBE THORACOSTOMY INCLUDES WATER SEAL
|
Professional
|
$278.50
|
|
|
Service Code
|
CPT 32551
|
| Hospital Charge Code |
z32551
|
| Min. Negotiated Rate |
$142.73 |
| Max. Negotiated Rate |
$242.77 |
| Rate for Payer: Aetna Medicare |
$142.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$242.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$242.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$164.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$157.00
|
| Rate for Payer: Cash Price |
$172.67
|
| Rate for Payer: Cash Price |
$172.67
|
| Rate for Payer: Coventry All Commercial |
$171.28
|
| Rate for Payer: Frontpath All Commercial |
$205.72
|
| Rate for Payer: Humana ChoiceCare |
$193.38
|
| Rate for Payer: Humana Medicare |
$142.73
|
| Rate for Payer: Lucent All Commercial |
$242.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$228.00
|
| Rate for Payer: PHCS All Commercial |
$208.88
|
| Rate for Payer: PHP All Commercial |
$194.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$142.73
|
| Rate for Payer: Signature Care EPO |
$206.99
|
| Rate for Payer: Signature Care PPO |
$206.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$214.00
|
| Rate for Payer: United Healthcare Commercial |
$206.70
|
| Rate for Payer: United Healthcare Medicare |
$142.73
|
|
|
PR TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE
|
Professional
|
$547.26
|
|
|
Service Code
|
CPT 12020
|
| Hospital Charge Code |
z12020
|
| Min. Negotiated Rate |
$170.52 |
| Max. Negotiated Rate |
$410.44 |
| Rate for Payer: Aetna Medicare |
$175.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$327.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$327.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$201.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$192.72
|
| Rate for Payer: Cash Price |
$339.30
|
| Rate for Payer: Cash Price |
$339.30
|
| Rate for Payer: Coventry All Commercial |
$210.24
|
| Rate for Payer: Frontpath All Commercial |
$240.51
|
| Rate for Payer: Humana ChoiceCare |
$170.52
|
| Rate for Payer: Humana Medicare |
$175.20
|
| Rate for Payer: Lucent All Commercial |
$297.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$228.00
|
| Rate for Payer: PHCS All Commercial |
$410.44
|
| Rate for Payer: PHP All Commercial |
$239.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$175.20
|
| Rate for Payer: Signature Care EPO |
$240.35
|
| Rate for Payer: Signature Care PPO |
$240.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$210.00
|
| Rate for Payer: United Healthcare Commercial |
$201.61
|
| Rate for Payer: United Healthcare Medicare |
$175.20
|
|
|
PR TX SUPERFICIAL WOUND DEHISCENCE W/PACKING
|
Professional
|
$322.94
|
|
|
Service Code
|
CPT 12021
|
| Hospital Charge Code |
z12021
|
| Min. Negotiated Rate |
$122.11 |
| Max. Negotiated Rate |
$242.20 |
| Rate for Payer: Aetna Medicare |
$131.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$150.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$144.36
|
| Rate for Payer: Cash Price |
$200.22
|
| Rate for Payer: Cash Price |
$200.22
|
| Rate for Payer: Coventry All Commercial |
$157.49
|
| Rate for Payer: Frontpath All Commercial |
$180.38
|
| Rate for Payer: Humana ChoiceCare |
$122.11
|
| Rate for Payer: Humana Medicare |
$131.24
|
| Rate for Payer: Lucent All Commercial |
$223.11
|
| Rate for Payer: PHCS All Commercial |
$242.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$131.24
|
| Rate for Payer: United Healthcare Commercial |
$146.21
|
| Rate for Payer: United Healthcare Medicare |
$131.24
|
|
|
PR TYMPANOMETRY
|
Professional
|
$30.40
|
|
|
Service Code
|
CPT 92567
|
| Hospital Charge Code |
z92567
|
| Min. Negotiated Rate |
$10.33 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Aetna Medicare |
$10.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.36
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Coventry All Commercial |
$12.40
|
| Rate for Payer: Frontpath All Commercial |
$11.51
|
| Rate for Payer: Humana ChoiceCare |
$22.05
|
| Rate for Payer: Humana Medicare |
$10.33
|
| Rate for Payer: Lucent All Commercial |
$17.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.00
|
| Rate for Payer: PHCS All Commercial |
$22.80
|
| Rate for Payer: PHP All Commercial |
$14.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.33
|
| Rate for Payer: Signature Care EPO |
$22.10
|
| Rate for Payer: Signature Care PPO |
$22.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.00
|
| Rate for Payer: United Healthcare Commercial |
$18.09
|
| Rate for Payer: United Healthcare Medicare |
$10.33
|
|
|
PR TYMPANOMETRY AND REFLEX THRESHOLD MEASUREMENTS
|
Professional
|
$41.52
|
|
|
Service Code
|
CPT 92550
|
| Hospital Charge Code |
z92550
|
| Min. Negotiated Rate |
$21.28 |
| Max. Negotiated Rate |
$36.18 |
| Rate for Payer: Aetna Medicare |
$21.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.41
|
| Rate for Payer: Cash Price |
$25.74
|
| Rate for Payer: Cash Price |
$25.74
|
| Rate for Payer: Coventry All Commercial |
$25.54
|
| Rate for Payer: Frontpath All Commercial |
$24.23
|
| Rate for Payer: Humana ChoiceCare |
$22.97
|
| Rate for Payer: Humana Medicare |
$21.28
|
| Rate for Payer: Lucent All Commercial |
$36.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.00
|
| Rate for Payer: PHCS All Commercial |
$31.14
|
| Rate for Payer: PHP All Commercial |
$30.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.28
|
| Rate for Payer: Signature Care EPO |
$22.10
|
| Rate for Payer: Signature Care PPO |
$22.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.00
|
| Rate for Payer: United Healthcare Commercial |
$24.74
|
| Rate for Payer: United Healthcare Medicare |
$21.28
|
|
|
PR ULTRASOUND,PELVIC NON-OB
|
Professional
|
$194.18
|
|
|
Service Code
|
CPT 76856
|
| Hospital Charge Code |
z76856
|
| Min. Negotiated Rate |
$99.51 |
| Max. Negotiated Rate |
$175.41 |
| Rate for Payer: Aetna Medicare |
$99.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$105.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$105.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$114.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$109.46
|
| Rate for Payer: Cash Price |
$120.39
|
| Rate for Payer: Cash Price |
$120.39
|
| Rate for Payer: Coventry All Commercial |
$119.41
|
| Rate for Payer: Frontpath All Commercial |
$175.41
|
| Rate for Payer: Humana ChoiceCare |
$115.73
|
| Rate for Payer: Humana Medicare |
$99.51
|
| Rate for Payer: Lucent All Commercial |
$169.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$154.00
|
| Rate for Payer: PHCS All Commercial |
$145.64
|
| Rate for Payer: PHP All Commercial |
$126.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$99.51
|
| Rate for Payer: Signature Care EPO |
$113.05
|
| Rate for Payer: Signature Care PPO |
$113.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$144.00
|
| Rate for Payer: United Healthcare Commercial |
$110.80
|
| Rate for Payer: United Healthcare Medicare |
$99.51
|
|
|
PR ULTRASOUND,TRANSVAGINAL NON-OB
|
Professional
|
$220.08
|
|
|
Service Code
|
CPT 76830
|
| Hospital Charge Code |
z76830
|
| Min. Negotiated Rate |
$105.30 |
| Max. Negotiated Rate |
$197.96 |
| Rate for Payer: Aetna Medicare |
$112.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$105.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$105.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$129.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$124.07
|
| Rate for Payer: Cash Price |
$136.45
|
| Rate for Payer: Cash Price |
$136.45
|
| Rate for Payer: Coventry All Commercial |
$135.35
|
| Rate for Payer: Frontpath All Commercial |
$197.96
|
| Rate for Payer: Humana ChoiceCare |
$130.82
|
| Rate for Payer: Humana Medicare |
$112.79
|
| Rate for Payer: Lucent All Commercial |
$191.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$175.00
|
| Rate for Payer: PHCS All Commercial |
$165.06
|
| Rate for Payer: PHP All Commercial |
$143.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$112.79
|
| Rate for Payer: Signature Care EPO |
$113.05
|
| Rate for Payer: Signature Care PPO |
$113.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$164.00
|
| Rate for Payer: United Healthcare Commercial |
$110.14
|
| Rate for Payer: United Healthcare Medicare |
$112.79
|
|
|
PR UNLISTED OTORHINOLARYNG SERVICE/PROC
|
Professional
|
$52.93
|
|
|
Service Code
|
CPT 92700
|
| Hospital Charge Code |
z92700
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$44.99 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$32.82
|
| Rate for Payer: Cash Price |
$32.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.99
|
| Rate for Payer: PHCS All Commercial |
$39.70
|
| Rate for Payer: Signature Care EPO |
$33.75
|
| Rate for Payer: Signature Care PPO |
$33.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.76
|
|
|
PR UNLISTED PROC, ARTHROSCOPY
|
Professional
|
$508.53
|
|
|
Service Code
|
CPT 29999
|
| Hospital Charge Code |
z29999
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$432.25 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$315.29
|
| Rate for Payer: Cash Price |
$315.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$432.25
|
| Rate for Payer: PHCS All Commercial |
$381.40
|
| Rate for Payer: Signature Care EPO |
$324.19
|
| Rate for Payer: Signature Care PPO |
$324.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$305.12
|
|
|
PR UPG PACEMAKER SYS CONVERT 1CHMBR SYS 2CHMBR SYS
|
Professional
|
$851.56
|
|
|
Service Code
|
CPT 33214
|
| Hospital Charge Code |
z33214
|
| Min. Negotiated Rate |
$436.43 |
| Max. Negotiated Rate |
$741.93 |
| Rate for Payer: Aetna Medicare |
$436.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$695.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$695.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$501.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$480.07
|
| Rate for Payer: Cash Price |
$527.97
|
| Rate for Payer: Cash Price |
$527.97
|
| Rate for Payer: Coventry All Commercial |
$523.72
|
| Rate for Payer: Frontpath All Commercial |
$626.55
|
| Rate for Payer: Humana ChoiceCare |
$614.85
|
| Rate for Payer: Humana Medicare |
$436.43
|
| Rate for Payer: Lucent All Commercial |
$741.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$698.00
|
| Rate for Payer: PHCS All Commercial |
$638.67
|
| Rate for Payer: PHP All Commercial |
$596.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$436.43
|
| Rate for Payer: Signature Care EPO |
$713.15
|
| Rate for Payer: Signature Care PPO |
$713.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$655.00
|
| Rate for Payer: United Healthcare Commercial |
$581.20
|
| Rate for Payer: United Healthcare Medicare |
$436.43
|
|
|
PR VAG DELIV ONLY,PREV C-SECTN
|
Professional
|
$1,589.64
|
|
|
Service Code
|
CPT 59612
|
| Hospital Charge Code |
z59612
|
| Min. Negotiated Rate |
$814.69 |
| Max. Negotiated Rate |
$1,384.97 |
| Rate for Payer: Aetna Medicare |
$814.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,072.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,072.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$936.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$896.16
|
| Rate for Payer: Cash Price |
$985.58
|
| Rate for Payer: Cash Price |
$985.58
|
| Rate for Payer: Coventry All Commercial |
$977.63
|
| Rate for Payer: Frontpath All Commercial |
$1,182.49
|
| Rate for Payer: Humana ChoiceCare |
$837.55
|
| Rate for Payer: Humana Medicare |
$814.69
|
| Rate for Payer: Lucent All Commercial |
$1,384.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,141.00
|
| Rate for Payer: PHCS All Commercial |
$1,192.23
|
| Rate for Payer: PHP All Commercial |
$1,049.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$814.69
|
| Rate for Payer: Signature Care EPO |
$1,074.40
|
| Rate for Payer: Signature Care PPO |
$1,074.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,059.00
|
| Rate for Payer: United Healthcare Commercial |
$976.96
|
| Rate for Payer: United Healthcare Medicare |
$814.69
|
|
|
PR VAG DELIV+POSTPARTUM CARE,PREV C-SEC
|
Professional
|
$2,010.88
|
|
|
Service Code
|
CPT 59614
|
| Hospital Charge Code |
z59614
|
| Min. Negotiated Rate |
$921.23 |
| Max. Negotiated Rate |
$1,752.24 |
| Rate for Payer: Aetna Medicare |
$1,030.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,164.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,164.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,185.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,133.80
|
| Rate for Payer: Cash Price |
$1,246.75
|
| Rate for Payer: Cash Price |
$1,246.75
|
| Rate for Payer: Coventry All Commercial |
$1,236.88
|
| Rate for Payer: Frontpath All Commercial |
$1,494.31
|
| Rate for Payer: Humana ChoiceCare |
$921.23
|
| Rate for Payer: Humana Medicare |
$1,030.73
|
| Rate for Payer: Lucent All Commercial |
$1,752.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,443.00
|
| Rate for Payer: PHCS All Commercial |
$1,508.16
|
| Rate for Payer: PHP All Commercial |
$1,327.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,030.73
|
| Rate for Payer: Signature Care EPO |
$1,182.35
|
| Rate for Payer: Signature Care PPO |
$1,182.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,340.00
|
| Rate for Payer: United Healthcare Commercial |
$1,093.85
|
| Rate for Payer: United Healthcare Medicare |
$1,030.73
|
|
|
PR VAG HYST,REV VAG/URETHR,FIX ENTEROCE
|
Professional
|
$1,637.12
|
|
|
Service Code
|
CPT 58270
|
| Hospital Charge Code |
z58270
|
| Min. Negotiated Rate |
$839.03 |
| Max. Negotiated Rate |
$1,426.35 |
| Rate for Payer: Aetna Medicare |
$839.03
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,128.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,128.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$964.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$922.93
|
| Rate for Payer: Cash Price |
$1,015.01
|
| Rate for Payer: Cash Price |
$1,015.01
|
| Rate for Payer: Coventry All Commercial |
$1,006.84
|
| Rate for Payer: Frontpath All Commercial |
$1,176.42
|
| Rate for Payer: Humana ChoiceCare |
$949.27
|
| Rate for Payer: Humana Medicare |
$839.03
|
| Rate for Payer: Lucent All Commercial |
$1,426.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,175.00
|
| Rate for Payer: PHCS All Commercial |
$1,227.84
|
| Rate for Payer: PHP All Commercial |
$1,080.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$839.03
|
| Rate for Payer: Signature Care EPO |
$1,066.75
|
| Rate for Payer: Signature Care PPO |
$1,066.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,091.00
|
| Rate for Payer: United Healthcare Commercial |
$997.95
|
| Rate for Payer: United Healthcare Medicare |
$839.03
|
|
|
PR VAG HYST,RMV TUBE/OVARY
|
Professional
|
$1,694.90
|
|
|
Service Code
|
CPT 58262
|
| Hospital Charge Code |
z58262
|
| Min. Negotiated Rate |
$868.63 |
| Max. Negotiated Rate |
$1,476.67 |
| Rate for Payer: Aetna Medicare |
$868.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,171.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,171.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$998.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$955.49
|
| Rate for Payer: Cash Price |
$1,050.84
|
| Rate for Payer: Cash Price |
$1,050.84
|
| Rate for Payer: Coventry All Commercial |
$1,042.36
|
| Rate for Payer: Frontpath All Commercial |
$1,217.37
|
| Rate for Payer: Humana ChoiceCare |
$985.89
|
| Rate for Payer: Humana Medicare |
$868.63
|
| Rate for Payer: Lucent All Commercial |
$1,476.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,216.00
|
| Rate for Payer: PHCS All Commercial |
$1,271.18
|
| Rate for Payer: PHP All Commercial |
$1,118.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$868.63
|
| Rate for Payer: Signature Care EPO |
$1,183.20
|
| Rate for Payer: Signature Care PPO |
$1,183.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,129.00
|
| Rate for Payer: United Healthcare Commercial |
$1,040.74
|
| Rate for Payer: United Healthcare Medicare |
$868.63
|
|
|
PR VAG HYST,RMV TUBE/OVARY,FIX ENTEROCE
|
Professional
|
$1,817.54
|
|
|
Service Code
|
CPT 58263
|
| Hospital Charge Code |
z58263
|
| Min. Negotiated Rate |
$931.48 |
| Max. Negotiated Rate |
$1,583.52 |
| Rate for Payer: Aetna Medicare |
$931.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,266.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,266.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,071.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,024.63
|
| Rate for Payer: Cash Price |
$1,126.87
|
| Rate for Payer: Cash Price |
$1,126.87
|
| Rate for Payer: Coventry All Commercial |
$1,117.78
|
| Rate for Payer: Frontpath All Commercial |
$1,305.46
|
| Rate for Payer: Humana ChoiceCare |
$1,066.08
|
| Rate for Payer: Humana Medicare |
$931.48
|
| Rate for Payer: Lucent All Commercial |
$1,583.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,304.00
|
| Rate for Payer: PHCS All Commercial |
$1,363.16
|
| Rate for Payer: PHP All Commercial |
$1,199.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$931.48
|
| Rate for Payer: Signature Care EPO |
$1,197.65
|
| Rate for Payer: Signature Care PPO |
$1,197.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,211.00
|
| Rate for Payer: United Healthcare Commercial |
$1,121.56
|
| Rate for Payer: United Healthcare Medicare |
$931.48
|
|
|
PR VAG HYST,UTERUS >250 GMS
|
Professional
|
$2,102.68
|
|
|
Service Code
|
CPT 58290
|
| Hospital Charge Code |
z58290
|
| Min. Negotiated Rate |
$1,077.62 |
| Max. Negotiated Rate |
$1,831.95 |
| Rate for Payer: Aetna Medicare |
$1,077.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,488.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,488.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,239.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,185.38
|
| Rate for Payer: Cash Price |
$1,303.66
|
| Rate for Payer: Cash Price |
$1,303.66
|
| Rate for Payer: Coventry All Commercial |
$1,293.14
|
| Rate for Payer: Frontpath All Commercial |
$1,514.40
|
| Rate for Payer: Humana ChoiceCare |
$1,252.98
|
| Rate for Payer: Humana Medicare |
$1,077.62
|
| Rate for Payer: Lucent All Commercial |
$1,831.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,509.00
|
| Rate for Payer: PHCS All Commercial |
$1,577.01
|
| Rate for Payer: PHP All Commercial |
$1,387.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,077.62
|
| Rate for Payer: Signature Care EPO |
$1,380.40
|
| Rate for Payer: Signature Care PPO |
$1,380.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,401.00
|
| Rate for Payer: United Healthcare Commercial |
$1,305.84
|
| Rate for Payer: United Healthcare Medicare |
$1,077.62
|
|
|
PR VAG HYST,UTERUS >250 GMS,REM TUBE/OVARY
|
Professional
|
$2,272.02
|
|
|
Service Code
|
CPT 58291
|
| Hospital Charge Code |
z58291
|
| Min. Negotiated Rate |
$1,164.41 |
| Max. Negotiated Rate |
$1,979.50 |
| Rate for Payer: Aetna Medicare |
$1,164.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,624.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,624.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,339.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,280.85
|
| Rate for Payer: Cash Price |
$1,408.65
|
| Rate for Payer: Cash Price |
$1,408.65
|
| Rate for Payer: Coventry All Commercial |
$1,397.29
|
| Rate for Payer: Frontpath All Commercial |
$1,637.12
|
| Rate for Payer: Humana ChoiceCare |
$1,366.92
|
| Rate for Payer: Humana Medicare |
$1,164.41
|
| Rate for Payer: Lucent All Commercial |
$1,979.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,630.00
|
| Rate for Payer: PHCS All Commercial |
$1,704.02
|
| Rate for Payer: PHP All Commercial |
$1,499.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,164.41
|
| Rate for Payer: Signature Care EPO |
$1,518.10
|
| Rate for Payer: Signature Care PPO |
$1,518.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,514.00
|
| Rate for Payer: United Healthcare Commercial |
$1,419.24
|
| Rate for Payer: United Healthcare Medicare |
$1,164.41
|
|
|
PR VAGINAL HYSTERECTOMY,UTERUS 250 GMS/<
|
Professional
|
$1,534.34
|
|
|
Service Code
|
CPT 58260
|
| Hospital Charge Code |
z58260
|
| Min. Negotiated Rate |
$786.35 |
| Max. Negotiated Rate |
$1,336.80 |
| Rate for Payer: Aetna Medicare |
$786.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,039.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,039.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$904.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$864.98
|
| Rate for Payer: Cash Price |
$951.29
|
| Rate for Payer: Cash Price |
$951.29
|
| Rate for Payer: Coventry All Commercial |
$943.62
|
| Rate for Payer: Frontpath All Commercial |
$1,100.88
|
| Rate for Payer: Humana ChoiceCare |
$874.55
|
| Rate for Payer: Humana Medicare |
$786.35
|
| Rate for Payer: Lucent All Commercial |
$1,336.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,101.00
|
| Rate for Payer: PHCS All Commercial |
$1,150.76
|
| Rate for Payer: PHP All Commercial |
$1,012.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$786.35
|
| Rate for Payer: Signature Care EPO |
$1,049.75
|
| Rate for Payer: Signature Care PPO |
$1,049.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,022.00
|
| Rate for Payer: United Healthcare Commercial |
$931.06
|
| Rate for Payer: United Healthcare Medicare |
$786.35
|
|
|
PR VAR VACCINE LIVE FOR SUBCUTANEOUS USE
|
Professional
|
$223.99
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
z90716
|
| Min. Negotiated Rate |
$153.00 |
| Max. Negotiated Rate |
$223.99 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$153.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$153.00
|
| Rate for Payer: Frontpath All Commercial |
$176.81
|
| Rate for Payer: Humana ChoiceCare |
$182.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$223.99
|
| Rate for Payer: PHP All Commercial |
$175.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$223.99
|
| Rate for Payer: United Healthcare Commercial |
$191.84
|
|
|
PR VASCULAR SURGERY PROCEDURE UNLIST
|
Professional
|
$708.53
|
|
|
Service Code
|
CPT 37799
|
| Hospital Charge Code |
z37799
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$602.25 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$439.29
|
| Rate for Payer: Cash Price |
$439.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$602.25
|
| Rate for Payer: PHCS All Commercial |
$531.40
|
| Rate for Payer: Signature Care EPO |
$451.69
|
| Rate for Payer: Signature Care PPO |
$451.69
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$425.12
|
|
|
PR VENT TUBE REMVL REQ GEN ANESTHESIA
|
Professional
|
$234.64
|
|
|
Service Code
|
CPT 69424
|
| Hospital Charge Code |
z69424
|
| Min. Negotiated Rate |
$56.65 |
| Max. Negotiated Rate |
$175.98 |
| Rate for Payer: Aetna Medicare |
$56.65
|
| Rate for Payer: Aetna Medicare |
$56.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$107.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$107.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$107.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$107.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$65.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$65.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$62.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$62.32
|
| Rate for Payer: Cash Price |
$290.95
|
| Rate for Payer: Cash Price |
$290.95
|
| Rate for Payer: Cash Price |
$145.48
|
| Rate for Payer: Cash Price |
$145.48
|
| Rate for Payer: Coventry All Commercial |
$67.98
|
| Rate for Payer: Coventry All Commercial |
$67.98
|
| Rate for Payer: Frontpath All Commercial |
$76.84
|
| Rate for Payer: Frontpath All Commercial |
$76.84
|
| Rate for Payer: Humana ChoiceCare |
$62.79
|
| Rate for Payer: Humana ChoiceCare |
$62.79
|
| Rate for Payer: Humana Medicare |
$56.65
|
| Rate for Payer: Humana Medicare |
$56.65
|
| Rate for Payer: Lucent All Commercial |
$96.30
|
| Rate for Payer: Lucent All Commercial |
$96.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.00
|
| Rate for Payer: PHCS All Commercial |
$351.96
|
| Rate for Payer: PHCS All Commercial |
$175.98
|
| Rate for Payer: PHP All Commercial |
$71.85
|
| Rate for Payer: PHP All Commercial |
$71.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$56.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$56.65
|
| Rate for Payer: Signature Care EPO |
$140.25
|
| Rate for Payer: Signature Care EPO |
$140.25
|
| Rate for Payer: Signature Care PPO |
$140.25
|
| Rate for Payer: Signature Care PPO |
$140.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.00
|
| Rate for Payer: United Healthcare Commercial |
$68.35
|
| Rate for Payer: United Healthcare Commercial |
$68.35
|
| Rate for Payer: United Healthcare Medicare |
$56.65
|
| Rate for Payer: United Healthcare Medicare |
$56.65
|
|
|
PR VISUAL AUDIOMETRY (VRA)
|
Professional
|
$84.26
|
|
|
Service Code
|
CPT 92579
|
| Hospital Charge Code |
z92579
|
| Min. Negotiated Rate |
$28.20 |
| Max. Negotiated Rate |
$63.20 |
| Rate for Payer: Aetna Medicare |
$35.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$28.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$28.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.35
|
| Rate for Payer: Cash Price |
$52.24
|
| Rate for Payer: Cash Price |
$52.24
|
| Rate for Payer: Coventry All Commercial |
$42.92
|
| Rate for Payer: Frontpath All Commercial |
$41.17
|
| Rate for Payer: Humana ChoiceCare |
$30.49
|
| Rate for Payer: Humana Medicare |
$35.77
|
| Rate for Payer: Lucent All Commercial |
$60.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$47.00
|
| Rate for Payer: PHCS All Commercial |
$63.20
|
| Rate for Payer: PHP All Commercial |
$50.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$35.77
|
| Rate for Payer: Signature Care EPO |
$37.55
|
| Rate for Payer: Signature Care PPO |
$37.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$43.00
|
| Rate for Payer: United Healthcare Commercial |
$48.49
|
| Rate for Payer: United Healthcare Medicare |
$35.77
|
|
|
PR VISUAL SCREENING TEST, BILAT
|
Professional
|
$5.14
|
|
|
Service Code
|
CPT 99173
|
| Hospital Charge Code |
z99173
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$13.09 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.48
|
| Rate for Payer: Cash Price |
$3.19
|
| Rate for Payer: Cash Price |
$3.19
|
| Rate for Payer: Frontpath All Commercial |
$2.93
|
| Rate for Payer: Humana ChoiceCare |
$13.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.00
|
| Rate for Payer: PHCS All Commercial |
$3.86
|
| Rate for Payer: PHP All Commercial |
$3.08
|
| Rate for Payer: Signature Care EPO |
$5.30
|
| Rate for Payer: Signature Care PPO |
$5.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.00
|
| Rate for Payer: United Healthcare Commercial |
$2.31
|
|
|
PR VITAMIN B12 INJECTION
|
Professional
|
$3.39
|
|
|
Service Code
|
CPT J3420
|
| Hospital Charge Code |
zJ3420
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$3.39 |
| Rate for Payer: Humana ChoiceCare |
$2.05
|
| Rate for Payer: PHP All Commercial |
$3.39
|
|
